华西医学

华西医学

不同入路连续腰丛神经阻滞用于股骨近端手术老年患者围手术期镇痛效果的比较

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目的 比较不同入路连续腰丛神经阻滞用于股骨近端手术老年患者围手术期镇痛的效果。 方法 选择 2015 年 1 月—12 月择期行股骨近端手术的患者 150 例,性别不限,年龄 60~90 岁,体质量 51~72 kg,美国麻醉医师协会分级Ⅰ~Ⅲ级。采用随机数字表法分为腰大肌间隙入路组(PCB 组)、Winnie“三合一”入路组(Winnie 组)和髂筋膜间隙入路组(FICB 组),每组各 50 例。手术前 12 h 在超声仪和神经刺激器辅助下行神经阻滞,置管后接电子自控镇痛泵,药物配方及使用方法相同。3 组均在硬膜外麻醉下进行手术。3 组维持术后镇痛 72 h,采用肌肉注射舒芬太尼 10 μg 行补救镇痛,维持静态视觉模拟评分(Visual Analogue Scale,VAS)≤3 分,主动活动 VAS 评分≤4 分。于术后评价患肢股四头肌肌力,记录术后 24 h 时股神经、股外侧皮神经和闭孔神经的阻滞有效情况。记录补救镇痛情况、穿刺点出血、硬膜外阻滞、神经损伤和感染等。 结果 PCB 组穿刺时 2 例出现硬膜外阻滞,1 例穿刺点出血,其余 2 组未见并发症发生。3 组均未进行补救镇痛。FIBC 组术后 24、48、72 h 患肢股四头肌肌力高于 PCB 组(P<0.05)。Winnie 组、PCB 组和 FICB 组股外侧皮神经阻滞有效率分别为 64%、91% 和 96%,两两比较差异均有统计学意义(P<0.05)。Winnie 组、PCB 组和 FICB 组闭孔神经阻滞有效率分别为 84%、89% 和 62%,FICB 组低于 PCB 组和 Winnie 组(P<0.05)。 结论 髂筋膜间隙入路连续腰丛神经阻滞用于股骨近端手术老年患者围手术期镇痛的效果确切,并发症较少,优于腰大肌间隙入路和 Winnie“三合一”入路。

Objective To explore the clinical effect and complications of lumbar plexus block through different approaches on perioperative analgesia in aged proximal femur surgery, and find the best method for analgesia in these patients. Methods From January to December 2015, 150 elderly patients scheduled for proximal femur surgery were randomly divided into three groups: psoas compartment block (PCB group, n=50), Winnie " 3 in 1” block (Winnie group, n=50), and fascia iliaca compartment block (FICB group, n=50). Twelve hours before surgery, guided by ultrasound and nerve stimulator, lumbar plexus blocks were performed in all the patients, then patient-controlled analgesia (the formula and the usage were the same) was done. All patients received epidural anesthesia, and were maintained postoperative analgesia for 72 hours. If Rest Visual Analogue Scale>3 or Initiative Movement Visual Analogue Scale>4, sufentanyl 10 μgi.m. was given. Muscle strength grades and complications were recorded. Anesthetic effect of sensory block of femoral, lateral femoral cutaneous, and obturator nerves were measured and recorded too. Results There were two cases of epidural block, and one case of puncture point bleeding in group PCB; no complication in the other groups was found. There was no remedy for inadequate analgesia in the three groups. Compared with group PCB, the muscle strength grades during postoperative 24–72 hours in group FICB were higher (P<0.05). The successful rate of the block of lateral femoral cutaneous nerves was 64%, 91% and 96% in group Winnie, group PCB and group FICB, respectively, and the differences between the three groups were all statistically significant (P<0.05). The successful rate of the block of obturator nerves in group FICB (62%) was lower than that in group PCB (89%) and Winnie group (84%) (P<0.05). Conclusion Continuous fascia iliaca compartment block on perioperative analgesia in aged proximal femur surgery, with exact effect, less complications and simple operation, is better than the psoas compartment block and Winne " 3 in 1” nerve block.

关键词: 腰骶丛; 神经传导阻滞; 手术期间; 镇痛; 老年人; 股骨骨折

Key words: Lumbosacral plexus; Nerve block; Intraoperative period; Analgesia; Aged; Femoral fractures

引用本文: 周颖, 凤婧, 杜鹏, 王光磊, 刘功俭. 不同入路连续腰丛神经阻滞用于股骨近端手术老年患者围手术期镇痛效果的比较. 华西医学, 2018, 33(9): 1142-1145. doi: 10.7507/1002-0179.201609012 复制

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